Pre-Consultation Form Now that you’ve scheduled your consultation, Please complete this Intake form: Name * Name First Name Last Name Email Address * Age * Health Concerns * Highest Weight Lowest Weight Last Bloodwork Date Last Bloodwork Date MM DD YYYY Can you submit a copy of your blood work 2 days before the consult? Yes No 1. What are your health/weight loss goals? 2. What are your expectations (nutritional counseling)? 3. Where are you now (in regards to weight and health) and where do you want to be? 4. How do you feel about your health and weight? 5. Are you ready to change habits that are keeping you from your goals? Yes No 6. Do you exercise regularly? Yes No 7. When do you usually go to bed? 8. How many hours of sleep do you get a night? 9. What are some goals you would like to reach in the next 30 days, 2 months, 4 months and 6 months? 10. Do you eat breakfast regularly? Yes No 11. Do you have any chronic conditions? If so, list them? 12. Do you have mid-day cravings? Yes No 13. What is stopping you from reaching your health goals? 14. If you could change anything about your health/weight what would you change? 15. What obstacles have kept you from reaching your health/weight loss goals in the past? 16. How do you feel when you reach your health goals? 17. How do you feel when you don’t reach your health loss goals? 18. What are your top 4 health goals? 19. Are your goals realistic? 20. What would you like a nutrition consultant to help you with? 21. How important is it for you to reach your health goals? 22. How important is it for you to reach your health goals? 23. Are you willing to make a commitment to reaching your health goals? Yes No 24. On a scale of 1-10 (most important), how important is it for you to live a healthier life?12345678910 25. What do you need to help you reach your health goals? 26. Are you ready to reach your health goals? Yes No 27. Do you have food allergies? 28. Have you tried other health/weight loss programs? If so what were they? 29. How much are you willing to invest in your health? 30. What health topics are you interested in learning more about? 31. Do you have any questions for me? Thank you!
